www.HIMSSConference.org
#PrecisionHIT
FEBRUARY 11, 2019
ORLANDO, FL
Determining Value of a
Precision Medicine Program
AURORA CANCER CARE
Sees 1 of every 4 cancer patients in Wisconsin
More than 8,000 new cancer patients/year
25,532 patients served
154 oncology physicians (38 Med Onc; 102
Surg Onc; 14 Rad Onc.)
19 Med Onc & 11 Rad Onc treatment locations
187 Cancer clinical trials
1,169 patients on cancer clinical trials
Joined with Advocate to become Advocate Aurora
Health 4/1/18. Collectively see over 16,000
new cancer patients per year.
AURORA CANCER CARE
Vertically Integrated, Pathways Driven (VIA Oncology),
multidisciplinary Cancer Care System
14 weekly video-conferenced disease specific cancer
conferences
All Medical Oncologists have primary and secondary disease
specific interests
Large NCORP program to prioritize clinical trials
Syapse for Molecular Tumor Board and data management
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Why Precision Medicine?
Precision Medicine presents new challenges for health care
Genetic data is increasingly used in decision making to determine best treatment
options
Identifies tumor genetic abnormalities (mutations) to select potential targeted
therapies
Opens a major new area for treatment of patients with advanced disease
A Precision Medicine Platform will:
“Get the data out of the file drawer,” and align EMR, labs and pharmacy information
Provide decision support for targeted therapies giving better capability to locate, understand, and
act upon molecular data
A single platform increases efficiency for ordering MDx tests and specialty meds
Provide automated Clinical Trials matching and more efficient provider communication
Position our service lines for a Precision Medicine future including: Cardiology, oncology,
neurosciences, orthopedics, women’s health, and behavioral health
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Sequential Therapy Results
With each line of therapy duration of sequential chemotherapy
generally LESS effective compared to prior therapy
Duration of PFS* (Second line Chemo) < 0.8
Duration of PFS (First line Chemo)
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*PFS=Progression free survival
Sequential Therapy ResultsMolecular Directed
With each line of therapy duration of sequential therapy
generally MORE effective compared to prior therapy
Duration of PFS (Molecular) > 1.3
Duration of PFS (first line Chemo)
Von Hoff et al, JCO 28(33):4877-4883,2010
Radovich et al. 2016 Oncotarget http://ow.ly/DBXD302mfub
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Molecular Testing
Requires precertification
Frequently requires 1-3 weeks for results
Report can be 25-35 pages
Physician analysis and discussion with patient can be 2
hours
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Benefits of Cancer Precision Medicine Program
Lay foundation for precision medicine program in all major service lines
Attract and retain patients seeking personalized medical care
Attract and retain professionals in the Precision Medicine category
With molecular and clinical data on a single platform: Increase our
workflow efficiencies, reduce error, eliminate duplication of tests and
med orders.
Standardize Clinical Trial data, and easily build cohorts for all service
lines. Much faster determination of eligibility for Pharma trials.
Increase Clinical Trials revenue.
Molecular Tumor Board can access data and convene virtually for
medical decisions
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Value depends on different perspectives
Perspective of the Institution
Perspective of the Patient
Perspective of the Provider
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Perspective of the Institution
Legitimate treatment for patients with (potentially) limited options
Cost of therapy
Cost of Care
Expense of PM program
Reimbursement rate for expensive drugs
Function of the MTB
Access to like patient results
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Perspective of the patient
Looking for legitimate options where none previously offered
Patients intuitively understand targeted therapythey have an alteration that
may increase chance of response.
Wants optimal treatment for cure or prolongation of quality life
Minimize toxicity and side effects, and financial toxicity of therapy that won’t
work
They see value in knowing how others have responded--Value of like patients
Expects Improved result with each drug
Understanding true costs
Value of MTB
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Perspective of the provider
Each successive chemotherapy treatment is generally less
successful
Molecular Therapy is currently most effective in advanced
disease
Limited good options for patients with advanced disease
Value of MTBprovides interpretation, advice and saves time
Drugs that work
Avoidance of drugs that don’t work
Cost of drug
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DAY
0
Day 1166
Swimmers plot of complex patient
PRECISION MEDICINE PROGRAM AND MOLECULAR
TUMOR BOARD
Started March 2017
Original estimate was 50 patients in first year
Passed 50 in July 2017
Morphed in that ordering/precerts now done by MTB staff
Assessment of tissue being studied
All reports fully reviewed and interpreted for Oncologists
Patients seen only if requested by treating oncologist
Full discussion if actionable result
MTB opinion returned to treating oncologist with recommendations
The Molecular Tumor Board--Weekly
Medical OncologistDirector
Pharm.DCo-Director
Molecular Pathologist
Genetic Counselor
Clinical Trials Nurse
Medical Oncologists
Radiation Oncologist
Surgical Oncologist
Others
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Molecular Tumor Board
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Stage IV Lung Adenocarcinoma: BRAF mutation
carboplatin & pemetrexed
chemotherapy
BRAF V600
mutation
dabrafenib & trametinib
anti-BRAF
$24,854/ Month AWP
0 2 4 6 8 10 12 14 16
Months
Since
Diagnosis
Stable disease per imaging
since month 9
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Stage IV Head and Neck Squamous Cell Carcinoma
cisplatin, fluorouracil,
& cetuximab
chemotherapy & anti-EGFR
carboplatin &
paclitaxel
chemotherapy
nivolumab
Anti-PD-1 immunotherapy
$15,330/month
0 5 10 15 20 30
Months
Since
Diagnosis
25
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Stage IV Lung Adenocarcinoma:
TMB High, PD-L1 positive; EGFR, ALK, ROS1 Negative
rituximab
anti-CD20
Lobectomy
2005 2010 2015
nivolumab
Anti-PD-1 immunotherapy
$15,330/month
2016 2017 2018 2019
Full Molecular Panel:
FGFR2 fusion
Stage I NSCLC
Follicular
lymphoma
Metastasis, lung primary
carboplatin, paclitaxel,
& bevacizumab
chemotherapy & anti-VEGF
Re-accumulation of the
pleural effusion
bevacizumab
anti-VEGF
$11,475 q3wk
New
supraclavicular
node
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Genetic Testing Referrals
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Monthly AWP cost of therapy
Drug Name
Disease
Molecular
Monthly/Cycle Cost
Aftatinib
NSCLC
Anti EGFR
$9,785
Cetuximab
Colon, Head and Neck,
NSCLC, Skin
Anti EGFR
$15,994
Vemurafenib
Melanoma
BRAF
+ Cobimetinib
Melanoma
MEK
Inhibitor
$20,557
Panitumumab
Colon
Anti
EGFR
$17,088
Erlotinib
NSCLC
Anti EGFR
$10,141
Dabrafenib
Melanoma
BRAF
+ Trametinib
NSCLC
MEK
Inhibitor
$24,854
Nivolumab
Multiple
Anti PD
-L-1
$15,330
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“NO MARGIN, NO MISSION”
Sister Irene Kraus
CEO, Daughters of Charity National Health System
There is value in our precision Medicine program
Patient’s Perspective
All potential avenues of therapy explored
Access to many clinical trials
Very comfortable with review of molecular data and recommendations
Understand that their Oncologist’s advice reinforced by large group
Like patient comparison may avoid less helpful treatment
Centralization of ordering/precertification reduces risk of large balance
bill
Some patients more comfortable electing palliative/hospice care
knowing options fully explored
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There is value in our precision Medicine program
Providers Perspective
Value of consultation from Molecular Tumor Board
Tremendous time saving allows more productive clinic time (MTB frees about
2 hrs per case)
Like patient analysis helpful in selecting drugs and also avoiding drugs
Marked increase in clinical trials referrals
Better able to counsel patients
Precertifications help to reassure patients regarding finances
Molecular platform improves ease of understanding
Increased referrals to the Hereditary Cancer Prevention and Management
Center (HCPMC)
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There is value in our precision Medicine program
Institution’s Perspective
Harder to document value in terms of $$
Definitely increases biopsies
Attracts new stage 4 patients
Offers new therapy not previously available
Increased referrals to Genetic Counselors and HCPMC which helps
family as well as the patientmay improve cancer prevention
Syapse platform helps identify clinical trials, similar patient matching for
+/- responders
Increase in clinical trials referrals
MTB and appropriate staff critical to success of program
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Thank You!
Special Thanks to:
Michael A. Thompson, MD, Ph.D., FASCO
Jennifer Godden, Pharm.D.
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www.HIMSSConference.org
#PrecisionHIT
James L. Weese, MD, FACS
Aurora Cancer Care, Advocate Aurora Health
@JimW9200